PAD and PAWS: Peripheral Arterial Disease and Prevention, Assessment, Wound management, Self-care

PAD and PAWS: Peripheral Arterial Disease and Prevention, Assessment, Wound management, Self-care

This service improvement programme aims to enable primary care staff to improve lower limb vascular assessments in patients with leg ulcers to allow appropriate treatment to start earlier.

Find your nearest AHSN

Coordinates

Overview

For people with leg ulcers, assessment of arterial blood supply, including ankle brachial pressure index (ABPI), is recommended to support safety of compression bandaging to aid wound healing. However, the time expense and specialised training required along with the lack of appropriate equipment or access to appropriate equipment to conduct manual ABPI assessment in primary care has necessitated referral into specialist services, thus delaying timely interventions.

This service improvement programme aimed to enable primary care staff to improve lower limb vascular assessments in patients with leg ulcers to allow appropriate treatment to start earlier. This was achieved through provision of 20 automated ABPI devices (MESI ABPI MD, Medi UK) to GP practices and a community clinic, associated with delivery of a comprehensive training, education and support package underpinning their use.

The devices were distributed to 19 GP practices (15 in East Staffordshire CCG, 2 in Stafford, 1 in Lichfield, 1 in Stoke-on-Trent) for use by GPNs and Healthcare Assistants (HCAs) in primary care with one device being utilised in a consultant-led community vascular clinic.

Training was designed to organise and equip primary care teams to effectively manage patient leg ulcers in primary care where appropriate, with a focus on prevention, early identification and ABPI assessment.

Whilst demonstrating clinical comparability to manual ABPI, automated ABPI provides a timely diagnosis in a primary care setting to enable initiation of appropriate compression treatment or onwards referral to accelerate commencement of appropriate wound care or treatment for vascular issues. Automated ABPIs also save time for all healthcare staff, save money for healthcare systems and contribute to improving the quality of life of patients with leg ulcers.

Impact & Outcomes

Quality & Efficiency

  • Completion of 145 ABPI assessments in the 11-month pilot thus avoiding the need for referral for ABPI measurement for these patients. Reasons for referral to GPNs for ABPI measurement included:
    • Lower limb wounds – 58% of patients (n=84)
    • Vascular concerns – 48% of patients (n=68)

*Note that some patients were referred with both wounds and vascular concerns

  • All 145 ABPI measurements were performed on primary care premises with 96% (n=139) being performed by GPNs and 4% (n=6) by health care support workers e.g. HCAs.
  • Demonstration of statistical and clinical comparability between manual and automated ABPI measurement (see publications in supporting materials) with a full range of ABPI values among recorded measurements including:
    • 12 patients below 0.6
    • 7 patients with 0.6-0.8
    • 113 patients with 0.8-1.3
    • 13 patients above 1.3   
  • Estimated time saving of 120 hours and 50 minutes nursing time released by conducting automated ABPI compared to manual ABPIs for the 145 assessments (24 hours 10 minutes for automated ABPI vs 145 hours manual ABPI), as reported by clinicians undertaking assessments.
  • Patients being allocated to an appropriate treatment pathway in a more timely manner including:
    • 66% of patients (n=96) being managed in general practice where management included:
      • 9% (n=13) started on statins, antiplatelet therapy or offered smoking cessation or exercise advice
      • 51% (n=74) offered lifestyle advice
      • 53% (n=77) offered skin care advice
      • 51% (n=74) commenced compression therapy
      • 23% (n=34) self-managing

*Note that many patients among the 96 received more than one of the above options

    • 34% of patients (n=49) were referred to specialist services including:
      • 18% (n=26) referred for vascular review
      • 3% (n=4) referred to district nurse service
      • 3% (n=5) referred to tissue viability nurses
      • 1% (n=2) referred to lymphoedema service
      • 3% (n=5) referred to leg ulcer clinics
      • 4% (n=6) referred back to GP
      • <1% (n=1) referred for duplex assessment to dermatology and orthopaedic specialists

**Note that a small number of patients were referred to specialist services and continued wound management in primary care and appear in both of the above categories.

  • Among respondents to a survey sent to staff during the pilot, 90% indicated they would to continue to use the ABPI device once the project was completed. Particular benefits of automated ABPI that respondents stated in the survey included the simplicity, speed, provision of result print outs, accurate detection of PAD, facilitation of early diagnosis and treatment, improved patient outcomes and timely onwards referral.  

Financial

  • Estimated financial savings of over £3,200 saved in staffing time through conducting automated ABPI compared to manual ABPI (as calculated from CCG average GPN rate of pay). These savings stand to increase as staff confidence in conducting automated ABPI increases.
  • Savings in total wound management costs of £32,259 between 2018 and 2019 for the 14 practices where results were returned, and prescribing expenditure information was available during this pilot (which ran from November 2018 – September 2019). Further analysis attributed these savings to reduction in the frequency of wound dressing changes, with patients being optimally managed with compression hosiery. Additionally, enhanced healing rates due to prompt management of leg ulcers contributed to these savings.   

Additional impacts include:

  • Accelerated ulcer healing times and reduced appointments (including redressing appointments) needed due to accelerated healing.
  • Improved and more frequent self-care by patients as GPNs are provided with more information on which to base appropriate advice to patients.
  • Easing the diagnostic and treatment caseload, and potentially waiting times, for vascular surgery outpatient clinics through increased management of patients in primary care (e.g. 75% of venous leg ulcers heal after 6 months compression therapy).
  • Prevention of cellulitis, sepsis or amputation which may be avoided through earlier identification of ulcers and associated risk factors or comorbidities (e.g. PAD, diabetes), when followed up by appropriate intervention.
  • Greater utilization of other staffing groups (E.g. HCAs) to conduct automated ABPI with GPNs interpreting results.